Prevention of Future Deaths reports · 2019
Regulation 28 report to prevent future deaths, reference 2019-0287, written 22 Jul 2019. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Jul 2019 |
|---|---|
| Reference | 2019-0287 |
| Deceased | Richard Carlon |
| Coroner | Louise Hunt |
| Coroner area | Birmingham and Solihull |
| Category | Alcohol, drug and medication related deaths · Mental Health related deaths · Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Birmingham and Solihull Mental Health Foundation Trust (BSMHT) 2. Chief Constable for West Midlands Police (WMP) 3. Birmingham City Council 1 CORONER I am Louise Hunt Senior Coroner for Birmingham and Solihull 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 21/12/2018 I commenced an investigation into the death of Richard Patrick Carlon. The investigation concluded at the end of an inquest on 22nd July 2019. The conclusion of the inquest was Suicide. 4 CIRCUMSTANCES OF THE DEATH The deceased had suffered from paranoid schizophrenia for many years and had been under the care of the Home Treatment Team receiving biweekly depot injections. He had a history of relapsing when taking illicit substances namely crack cocaine, cannabis and heroin. He did not engage with the MH team in October 2018. On 13/11/18 he attended Birmingham Heartlands Hospital emergency department with a relapse of his condition due to taking crack cocaine. He remained in the department overnight and following assessment at 10.10 on 14.11.18, when he appeared calm and insightful of what had happened, he was discharged to the care of the home treatment team. At 19.35 on 14/11/18 the deceased called WMP saying he would kill himself. Officers attended his mother’s address and detained him under S136 of the Mental Health Act and took him to a place of safety where he was assessed and admitted as a voluntary patient. On the morning of 15/11/18 the deceased asked to go for a cigarette. He did not wait for a doctor’s assessment so was escorted by a member of staff. He ran away from the member of staff who caught up with him however he stated he wished to leave but would return at 20.00. Mental Health notified WMP that he was absent but no log was created. At 15.09 the deceased mother rang to report him missing and officers were dispatched to investigate. There was confusion around whether he was in fact missing. At 21.07 he was found safe and well at his father’s home where he remained overnight. On 16/11/18 he remained at his father house leaving and returning several times. He last left at 21.30 saying he was going to see a friend. At 22.15 on 16/11/18 the deceased was seen on a lorry webcam to step in front of the lorry travelling along the A45 Coventry Road. He was taken to QE hospital emergency department where he was noted to have multiple injuries including a severe head injury. He was admitted to ITU and subsequently died on 14/12/18. Based on information from the Deceased’s treating clinicians the medical cause of death was determined to be: POLYTRAUMA ROAD TRAFFIC COLLISION 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – 1. No approved Mental Health practitioner was available to make the Mental Health Act assessment of Mr Carlon on 14/11/18. I was told this was an ongoing problem and was delaying assessments. 2. When Mr Carlon was found safe and well at home WMP did not advise BSMHT. This was a missed opportunity for Mental health to re‐engage with Mr Carlon and make a further assessment of his condition.Consideration need to be given to how agencies can improve communication. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 26 September 2019. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the family I have also sent it to NHS England and the CCG who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 22/07/2019 Signature Louise Hunt Senior Coroner Birmingham and Solihull
2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Birmingham i | City Council Background This response is provided by Birmingham City Council (BCC) in response to the regulation 28 report to Prevent Future Deaths, dated the 22nd July 2019, made by Louise Hunt, Senior Coroner for Birmingham and Solihull areas, under paragraph 7, schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. This report was.made following an Inquest touching upon the death of. Mr Richard Patrick Carlon. BCC was not an Interested Person and took no part in the Inquest. Mr Carlon died on the 14 December 2018. The conclusion of the Inquest on 22™ July 2019 was Suicide. At the outset of this response, the Local Authority expresses its deepest condolences to the family of Mr Carlon. The matter of concern relating to BCC was that no Approved Mental Health Professional (AMHP) was available to make the requested Mental Health Act Assessment (MHAA) of Mr Carlon in the early hours of the 14'" November 2018, the Coroner having been told that this was an ongoing problem and was delaying assessments. It is understood that in delivering her findings of fact, the Coroner stated in the inquest that had the MHAA taken place it would not have changed the outcome for Mr Carlon. AMHP resources and decisions made on the 14" November 2018 At 00.17am on the 14" November 2018 a referral was received, by BCC’s Emergency Duty Team, requesting a MHAA be undertaken in respect of Mr Carlon, who was at the time awaiting assessment in the Accident and Emergency (A&E) department at the Heartlands Hospital. There was at the time no completed ‘Medical Recommendation’, nor an available psychiatric bed. A MHAA is usually initiated with the provision of a first medical recommendation confirming that the patient is suffering from a-mental disorder of a nature or degree which’ either ‘warrants the detention of the patient in hospital for assessment’ (Section 2) or 'makes it appropriate for the patient to receive medical treatment in hospital’ (Section 3). (The Mental Health Act 1983: Criteria for detention Royal College of Psychiatrists 22.01.2018) To provide some.context on the management criteria in cases such as this: e All MHAA referrals are screened and prioritised and as Mr Carlon was in a hospital setting therefore deemed to be in a place of safety. In situations like this where the service is in receipt of multiple referrals the priority would always be those in the community or those individuals in police custody presenting a risk to themselves and the public. ; ; e Where an individual may appear to be under the influence of alcohol or drugs, a decision to defer assessment is always made (as per Mental Health Act 1983) until the person is no longer under the influence of substances. The reason is that the influence of the substances affects the outcome of the assessments. The Out of Hours AMHP service is part of BCCs Emergency Duty cover. Mr Carlon was not an emergency due to being in a place of safety and hence a decision was made to pass the referral to the day time AMHP service. This was communicated to the Heartlands. . Birmingham i | City Connell On the 14" November 2018 .at 10.51 AM, when the day time service contacted the Heartlands hospital Mr Carlon was cooperating with Mental Health Service and a MHAA was not required. There was a further MHAA referral on the night of the 14th November 2018, a MHAA was undertaken by a BCC AMHP, and an application for admission under the Mental Health Act (MHA) was not required as Mr Carlon agreed to an informal admission. The MHA requires the ‘Least Restrictive’ option to be undertaken; this was deemed to be an informal admission on this occasion. Mr Carlon left the hospital on the 15" November 2018, there was no request received for a MHAA following this. Mr Carlon subsequently stepped in front of a motor vehicle on the 16" November 2018 and died from his injuries on the 14"° December 2018. . AMHP availability In response to the ongoing issue of AMHP availability leading to delays in assessments, below is a brief synopsis of the process adopted and the work currently being undertaken by BCC to bring about improvements around the availability of the AMHP service. if Local Social Services have reason to think that an application for admission to hospital or a guardianship application may need to be made in respect of a patient within their area, they shall make arrangements for an approved mental health professional to consider the patient's case on their behalf (Mental Health Act 1983, Section 13). .If the AMHP then determines that a MHAA is needed they will coordinate and undertake the MHAA. This should be done in a timely manner. The coordination role involves the AMHP being multi agency dependant. It is this that will often impact on time scales for MHAAs being completed rather than availability of AMHPs who may well be coordinating MHAAs and chasing up partner agencies. The availability of partner agency resources as opposed to AMHP prioritisation decisions by AMHPs and partners, can involve people undergoing more than one MHAA before resources become available to allow a suitable outcome. The consideration and coordination will involve prioritisation of cases. The AMHP has the responsibility to coordinate the MHAA, including partner resources, but does not have the authority to prioritise partner resources. The current model of AMHP service delivery is being reviewed by BCC. Attached to this response is a statement that provides detailed information on the steps that will be taken to improve the service. The key to the successful delivery of this plan with be joint working with all partners. A project board meeting which serves as a governance body for the improvement work around the AMHP service in Birmingham was held on 11" September 2019. The board reviewed the plan providing solutions to system wide issues impacting the work of the AMHEPs. It should be reiterated that the review identified a total of 60 areas for improvement and 20 of these were related to whole systems partnership working. Birmingham @ | City Connell In the main these consisted of strategic level actions that addressed the longer-term issues needed to bring about sustainable improvements to the system. Some of the key actions were linked to.commissioning of'urgent beds for both Adults and Children and Young People and developing-a clear urgent care pathway for Birmingham. From an operational perspective the board considered adopting an information sharing system developed by Birmingham Council for Voluntary Services to help manage the cohort of individuals who frequently present with multiple and complex needs. The idea would be that any service that the individual comes into work with will have the ability to access history and records for the individual including information about homelessness and access to services such as drug and alcohol, make referrals to other services and review outcomes and risks. The other area that was agreed on was a workshop being held to agree improved joint working between the Mental Health Trust and the AMHP service. This workshop will be set up very shortly. The board has agreed to meet on a monthly basis and will become the vehicle for overseeirig the improvement work. There is a commitment to drive forward the improvements that have been identified as vital, to ensuring a better whole system, improved partnership working and preventing tragedies such as this occurring in the future. Title: Director coy Neupkavheode ( on behud oF Ehicey Checufite ) Date: 28)4 [2014
Keeping our Communities Preventing crime, protecting Safe and Reassured the public and helping those in need STAFFORDSHIRE AND WEST MIDLANDS POLICE JOINT LEGAL SERVICES ‘Director of en Services Sent via email Your Ref: 127686 F.A.O. HM Senior Coroner Our Ref: L14002548/TW Birmingham & Soiifull Districts Email: jointlegalservices@west-midlands.pnn.police.uk Date: 7 October 2019 Dear Sir or Madam, Mr Richard Carlon Please accept our apologies for the delayed response. In response to paragraph 5.2 of the report, West Midlands Police has reviewed the practical application of the new ‘Missing Persons - Authorised Professional Practice’, implemented in May 2019. As part of this review, it has been agreed that WMP Call Handlers will receive further guidance on the management of calls, and the subsequent procedures involved in incident log grading and management. : As part of this, it has been agreed that West Midlands Police will ensure any caller is updated when a missing person has been located to allow further contact between parties. This may not always mean full details of whereabouts are disclosed (as individual cases may prevent this from being appropriate) however, the reasons for this will be recorded and explained in each case. Notwithstanding the above, West Midlands Police will ensure the caller is updated in each case. Timescales for full implementation are by November 2019. We apologise again for the delayed response and hope the above assists however, please do not hesitate to contact us should the Coroner have any queries whatsoever. Yours faithfully, Staffordshire Office Joint Legal Services Staffordshire Police Headquarters West Midlands Police PO Box 3167 Lloyd Hause ,Colmore Circus Stafford, ST16 9JZ Birmingham , B4 6NQ Tel: 01785 232259 Tel: 0121 626 8317 - Fax: 0121 626 8272 Please be aware that all information provided to Staffordshire and West Midlands Police Joint Legal Services will be held and treated in confidence in accordance with the Data Protection Act 2018. It may be shared with other Force departments or third party organisations including, but not limited to, ° external solicitors, Counsel and, in relation to claims handling, Insurers. Personal information may also be used for statistical purposes, for fraud and crime prevention and may be checked with/disclosed to regulatory bodies. The information provided may be held electronically and/or in paper form and will be kept secure at all times. Please be aware that your personal data will be processed for the performance of tasks carried out in the public interest or in the exercise of the Police's official authority, and to comply with legal obligations. *Calls may be monitored and/or recorded for security, quality control or training purposes. Regulated by the Solicitors Regulatory Authority WE DO NOT ACCEPT SERVICE OF DOCUMENTS BY EMAIL OR FAX
See every Prevention of Future Deaths report matching Alcohol, drug and medication related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.